Care plan for an elderly patient with recurrent syncope

Care Plan

Patient Introduction:

The patient is a 85-95 years old Caucasian male who admitted to an acute rehab facility on April 11, 2016 after suffering a syncopal episode (loss of consciousness) and fell in the dining hall at Brighton Gardens nursing home. Patient has no memory of the events surrounding the fall and transporting to the hospital. He stated last thing he remembered was sitting in the dining hall with other residents and when he woke up he was already in the hospital.

Prior to his admission into the rehab facility, the patient was brought to Suburban hospital on April 4, 2016 after suffering a syncopal episode and stayed at the hospital for a week. While he was into the hospital, he had loop recorder placed to record arrhythmia. He also had ultra sound of the carotid arteries, Magnetic Resonance Imaging (MRI) of the brain, Magnetic Resonance Angiogram (MRA) of the head and Computerized tomography (CT). The ultrasound showed calcified plaque without hemodynamically significant stenosis of the right and left internal carotid arteries. The MRI showed atrophy and small vessel ischemic changes and no definite acute intracranial abnormality, which indicated transient ischemic attack. The MRA showed normal MR angiography of the circle of Willis. The CT of brain and head showed no acute intracranial abnormality including no acute hemorrhage or identified recent territorial infarct was seen. The CTA of chest showed no evidence of pulmonary embolus or acute inflammatory process in the chest, stable atelectasis at the right lung base, and right thyroid nodule.

The patient's past medical history includes hyperlipidemia, hypertension, atrial fibrillation, coronary artery disease, myocardial infarction, chronic kidney disease, benign prostatic hyperplasia, and irritable bowel syndrome. In 1997, he had two surgeries done: coronary artery bypass grafting and removing bladder stones.

The patient was born and raised in Pennsylvania, then moved to Maryland with his wife and two sons in 1970. He was in the army for two years after finishing high school. Then, he was a carpenter and in construction business for some time before he went to business school and graduated with an accounting degree. He met his wife while working as an accountant in Pennsylvania. They had been married for fifty-two years, she passed away ten years ago. He stated that both his parents had passed away: father died in his 50s from "stomach ulcer" and mother died in her 70s from stroke. He stated he started to drink and smoke when he was in the army, but quitted smoking and drinking in 1954 when he started to get chest pain and her wife asked him to stop. He used to smoke a pack per day.

Due to his syncopal episode, the patient cannot perform activities of daily living without assistance. He can bed bath and feed himself; however he needs to have someone assists him with walking to a bathroom. He can walk a short distance with a walker, but sometimes he needs to be in a wheelchair. At the rehab facility, he reported experiencing vertigo and weakness with his lower extremities bilaterally. He also stated he usually has pain on his legs every day when the evening time comes which prevents him to do any activities.

The patient does not have any known allergies. The patient's code status is full code.

Assessment and Interpretation:

April 23, 2016 13:00 Head-to-Toe Assessment

Assessment

Problems:

Vital Signs:

Temperature: 96.6 F (Oral)

Heart Rate: 65 beats per minute

Respirations: 20 breaths per minute

Blood Pressure: 152/76 mm

SpO2: 98% (Room Air)

Decreased cardiac output r/t atrial fibrillation and hypertension AEB increased blood pressure (Doenges et al., 2013, p. 172-173).

Psychosocial:

Posture is erect in bed and position is relaxed. Patient is awake, alert, and aware of stimuli. Patient's facial expression and speech is appropriated. Patient's mood and affect is mellow, but hopeless. Patient stated "I will never get out of here." Recent memory and remote memories intact. Patient can give great details of his life history. Thought coherent.

Hopelessness r/t prolonged activity resection, deteriorating physiological condition, loss of self-independence AEB patient believes things will not get better for him and patient stated "I will never get out of here" (Doenges et al., 2013, p. 485-486).

Neurologic:

Alert and oriented to person, place, time and situation.

Cranial Nerves:

I -- Not assessed.

II -- Test suggests peripheral vision intact

III, IV, VI -- Extraocular muscles intact. Pupils are equally round, reactive to light and accommodation bilaterally. Eye movement is parallel. No nystagmus.

V -- Not assessed.

VII -- Patient can smile, frown and puff up his cheeks.

VIII -- Patient can hear when talking.

IX, X -- Not assessed.

XI -- Patient can lift both shoulders against resistance.

XII -- Patient can say "light, tight, dynamite." "

Gait: Observed when the patient went to the bathroom. He walked with a walker and had a nursing assistance with him. All extremities are symmetric bilaterally. Patient can move his extremities with full range of motion and can feel sensation all around his body throughout the assessment when touch.

Musculoskeletal:

Patient's joints and muscles symmetric. No joint swelling, redness, masses, deformity. Full range of motion in all extremities; however, muscle strength is rated 5/5 equally in upper extremities and 3/5 equally in lower extremities. Patient's body movements are slow when walking to the bathroom with a walker and a supervisor. Patient stated having stabbing pain on his lower extremities every evening time.

Impaired physical mobility r/t decreased muscle strength, pain on his legs, activity intolerance and deconditioning AEB slowed movement, postural instability -- standing and walking, inability to move or transfer (Doenges et al., 2013, p. 611-612).

Self-care deficit: bathing, dressing, feeding, toileting r/t muscle weakness on lower extremities, pain on his legs, impaired mobility AEB inability to perform ADLs -- inability to get to the bathroom independently (Doenges et al., 2013, p. 787-788).

Impaired comfort r/t stabbing pain on patient's legs that he gets every evening AEB self-reported of being uncomfortable, lack of ease in situation and disturbed sleep pattern (Doenges et al., 2013, p. 210-211).

Cardiovascular:

Precordium: no abnormal pulsations and no heaves. Carotid artery pulses are 2+ bilaterally, no bruits, no apical pulsation and apical pulse heard at 5th intercostal space at the midclavicular line with normal rate and rhythm; heart sound was normal S1 and S2. No S3, S4 or murmur. Skin on extremities is dry, intact, no lesion, symmetric, no edema on upper and lower extremities. Radial pulses are 2+ bilaterally, dorsalis pedis and posterior tibial pluses are 2+ bilaterally; capillary refill is less than 3 seconds in all the upper and lower extremities with warm temperature. Localized hypothermia is felt on both feet.

Ineffective peripheral tissue perfusion r/t hypertension and sedentary lifestyle AEB self-reported of pain and decreased temperature in lower extremities (Doenges et al., 2013, p. 957-958).

Respiratory:

No abnormal breath sounds, lung sounds are clear throughout lung fields to auscultation. No masses noted upon palpation of anterior thorax.

Gastrointestinal:

Abdomen is flat, non-distend and symmetric. Skin is smooth with no lesions, scars, or striae. Bowel sounds present, no bruits. Abdomen is soft, no mass or tenderness upon light palpation. No pain reported.

Genitourinary:

The patient uses urinal while lying in bed. Patient's urination is light yellow color and clear. Patient reported of his usual urinary pattern -- 3-4 times a day.

Integumentary:

Skin: color is appropriated to patient's ethnicity, warm, dry, intact, even, smooth throughout body; no lesions. No pallor, erythema, cyanosis, or jaundice. There were surgical scars on his chest. Hair: grey color, even distribution with good texture. Nails: no clubbing / cyanosis, capillary refill is less than 3 seconds bilaterally. Localized hypothermia is felt on both feet.

Ineffective peripheral tissue perfusion r/t hypertension and sedentary lifestyle AEB self-reported of pain and decreased temperature in lower extremities (Doenges et al., 2013, p. 957-958).

Risk for impaired skin integrity r/t hypothermia on lower extremities, physical immobility and incontinence (Doenges et al., 2013, p. 864).

HEENT:

Head: normocephalic. Face: symmetric. Eye: conjunctivae clear and sclera white. No lesion or redness. Ears: pinna - no mass, lesions, discharge or tenderness to palpation. Neck: supple with full ROM, no mass. Trachea: midline. Mouth: mucosa and gingivae pink and moist; tongue symmetric, protrudes midline.

Lab Results:

Lab and radiology data results are correctly interpreted in light of the patient's history and current condition. Normal and abnormal interpretation of lab and radiology data is interpreted and discussed for significance to patient status and disease pathology. Preferably looking at multiple dates for comparative analysis. If lab/diagnostic data is unavailable, discuss what would be warranted or recommended with appropriate cited rationale (REFERENCES NOT OLDER THAN 5 YEARS).

For example: labs, why is it normal or why would it be high/low according to patient history and current condition. The patient has low hemoglobin and hematocrit because they are anemic.

Lab

Patient Value 04/12/16

Patient Value

Normal Range

Significance

Sodium

136-145

Within Range

Potassium

3.7

3.5-5.5

Within Range

Chloride

98

98-110

Within Range

Carbon Dioxide

28

21-31

Within Range

Anion Gap

13.7

12.0-20.0

Within Range

Glucose

98

70-105

Within Range

BUN

22

7-25

Within Range

Creatinine

0.93

0.6-1.3

Within Range

B/C Ratio

23.7

8.0-25.0

Within Range

Calcium

8.69

8.5-10.8

Within Range

ALT (SGPT)

8

7-52

Within Range

AST (SGOT)

18

13-39

Within Range

Alkaline Phosphate

63

34-104

Within Range

Total Bilirubin

1.5 (high)

0.3-1.4

Patient may be experiencing hemolytic anemia or problems with the liver.

Total Protein

5.9 (low)

6.0-8.3

Low total protein may signal malabsorption, malnutrition, and or liver/kidney problems.

Albumin

3.37 (low)

3.5-5.7

Low albumin may be caused by a poor nutrition state or congestive heart failure or kidney dysfunction.

Globulin

2.5

2.2-4.2

Within Range

A/G Ratio

1.3

0.8-2.0

Within Range

GFR Caucasian

77

>60 ml/min/1

Within Range

GFR African-American

93

>60 ml/min/1

Within Range

WBC

7.5

4-11

Within Range

RBC

4.03 (low)

4.1-6.2

This anemia could be caused by chronic inflammatory disease or a combination of nutritional deficiency and kidney failure.

Hemoglobin

12.4 (low)

13.5-17.5

May indicate anemia from cirrhosis.

Hematocrit

37.8 (low)

41-53

This anemia could be caused by malnutrition, as in low vitamin b12 levels or cancer.

MCV

94

80-97

Within Range

MCH

30.9

26-32

Within Range

MCHC

33.0

32-37

Within Range

RDW

14.3

11.5-14.5

Within Range

Platelet Count

130-400

Within Range

Neutrophil %

56.4

40-74

Within Range

Lymphocyte %

27.6

19-48

Within Range

Monocyte %

10.8

2-11

Within Range

Eosonophil %

4.1

0-7

Within Range

Basophil %

1.1

0-1.5

Within Range

Neutrophil #

4.3

1.7-7.7

Within Range

Lymphocyte #

2.1

1-4.8

Within Range

Monocyte #

0.8

0-1

Within Range

Eosinophil #

0.3

0.04-0.45

Within Range

Basophil #

0.1

0.00-0.20

Within Range

Medications:

The patient is taking Norvasc because they have a history of high blood pressure.

DRUG

Generic name and trade name

DOSE, ROUTE,

FREQUENCY,

Therapeutic Dose

MOA

DRUG CLASS

INDICATION

Carvedilol Oral Tablet

(Coreg)

(Skidmore-Roth, 2015, p. 210).

25 MG, 1 Tab, PO, 2X Daily at 9AM and 5PM

Therapeutic dose

A combination of nonselective a-/b-adrenergic blocking activity; reduces cardiac output, exercise-induced tachycardia, reflex orthostatic tachycardia;

causes vasodilation, decrease in peripheral vascular resistance

Antihypertensive and adrenergic blocker

Essential hypertension alone/mixed with other antihypertensives,

CHF, cardiomyopathy

Finasteride Oral Tablet

(Propecia or Proscar)

(Skidmore-Roth, 2015, p. 507).

5 MG 1 Tablet PO 1X Daily at 9PM

Therapeutic dose

Inhibits development of BHP; Inhibits 5-a-reductase as well as decrease in DHT; DHT induces androgenic effects via binding to androgen receptors

within cell nuclei of prostate gland, liver, skin;

Hormone, androgen inhibitor,

hair stimulant

Male-pattern baldness

GuaiFENesin Oral Tablet

(Tussin/Alfen/Mucinex)

(Skidmore-Roth, 2015, p. 580).

400 MG 1 Tablet PO 3X Daily at 6AM, 2PM, 10PM

Therapeutic dose

Increases volume as well as decreases the viscosity of secretions in bronchi and trachea to enable secretion removal

Expectorant

Productive and nonproductive

Cough

Lisinopril Oral Tablet

(Prinivil, Zestril)

(Skidmore-Roth, 2015, p. 717).

20 MG 1 Tablet PO 1X Daily 9AM

Therapeutic dose

Inhibits

ACE, thereby inhibiting conversion of angiotensin I to angiotensin II; Selectively suppresses renin-angiotensin-aldosterone

system;

Antihypertensive, angiotensin-converting

enzyme 1 (ACE) inhibitor

Mild to moderate hypertension, adjunctive therapy of systolic CHF, acute

MI

Omeprazole Oral Capsule Delayed Release

(NexIUM)

(Skidmore-Roth, 2015, p. 884-885).

20 MG 1 Capsule 1X Daily at 6:30AM

Therapeutic dose

Suppresses gastric secretions by inhibiting hydrogen/potassium

ATPase enzyme system in gastric parietal cell; characterized as gastric acid pump inhibitor because it blocks the final step of acid production

Antiulcer

Gastroesophageal reflux disease

(GERD), adult/child/infant; severe erosive esophagitis, adult/child; treatment of active duodenal ulcers in combination

with antiinfectives for Helicobacter

pylori infection; long-term usefor hypersecretory conditions

Oxybutynin Chloride ER Oral Tablet Extended Release 24-Hour (Ditropan/Gelnique)

(Skidmore-Roth, 2015, p. 896).

5 MG 1 Tablet PO at 9PM

Therapeutic dose

Relaxes smooth muscles in urinary tract via inhibiting acetylcholine at postganglionic sites

Anticholinergic

Antispasmodic for neurogenic

Bladder

Phillips Colon Health Oral Capsule

(Skidmore-Roth, 2015, p. 738).

1 Capsule PO 1X Daily at 9AM

Therapeutic dose

Increases osmotic pressure by drawing fluid into the colon and neutralizing HCl

Electrolyte; anticonvulsant;

saline laxative, antacid

Constipation; Electrolyte

Pravastatin Sodium Oral Tablet

(Livalo)

(Skidmore-Roth, 2015, p. 968).

20 MG 1 Tablet PO at 9PM

Therapeutic dose

Inhibits HMG-CoA reductase enzyme, which reduces cholesterol synthesis;

high doses lead to plaque regression

Antilipidemic

As an adjunct for primary hypercholesterolemia

(types Ia, Ib), dysbetalipoproteinemia, elevated triglyceride levels, prevention of CV disease by reduction of heart risk in those with mildly elevated cholesterol

Tamsulosin HCL Oral Capsule

(Flomax)

(Skidmore-Roth, 2015, p. 1120).

0.4 MG 1 Capsule PO at 9PM

Therapeutic dose

Binds preferentially to-a1Aadrenoceptor

subtype, which is located mainly in the prostate

Selective a1-peripheral adrenergic blocker, BPH agent

Symptoms of benign prostatic?

hyperplasia?(BPH)

PRN Medications

Maalox Advanced Oral Suspension

(Calcium Carbonate)

(Skidmore-Roth, 2015, p. 186).

200-200-20 MG/5ML 20 Milliliter PO to Abdomen, Chest PRN 1X Daily

Neutralizes gastric acidity

Antacid, calcium supplement;

not suitable for chronic therapy, hyperphosphatemia, hypertension during

pregnancy, osteoporosis, prevention, treatment of hypocalcemia, hypoparathyroidism

Calcium Supplement, Antacid

Acetaminophen Oral Tablet

(Equaline/Tylenol)

(Skidmore-Roth, 2015, p. 8).

325 MG 3 Tablet PO PRN Every 6 Hours

Temporarily blocks pain impulses peripherally that happen in reaction to inhibition of prostaglandin synthesis; antipyretic action results from inhibition of prostaglandins in the CNS; does not have anti-inflammatory properties;

Nonopioid analgesic,

Antipyretic

Pain

Diazepam Oral Tablet

(Diazemuls, Diastat, Valium)

(Skidmore-Roth, 2015, p. 356).

2 MG 1 Tablet PO PRN Every 8 hours

Potentiates the actions of GABA, especially in the limbic system, reticular formation; enhances presympathetic inhibition, inhibits spinal polysynaptic afferent paths

Antianxiety, anticonvulsant skeletal muscle relaxant, central acting

Anxiety, acute alcohol withdrawal, adjunct for seizure disorders;

preoperatively as a relaxant for skeletal muscle relaxation; rectally for acute repetitive seizures

(bisacodyl)

Dulcolax Rectal Suppository

(Skidmore-Roth, 2015, p. 145).

10 MG 1 Suppository PER RECTUM PRN 1X Daily

Believed to exasperate colonic intramural plexus by acting directly on intestine via increased motor activity

Stimulant, laxative

Constipation

Fleet Mineral Oil Rectal Enema

(Skidmore-Roth, 2015, p. 386).

1 Application PER RECTUM PRN 1X Daily

Increases water, fat penetration in intestine; allows for easier passage of stool

Laxative, emollient;

stool softener

Prevention of dry, hard stools

Imodium A-D Oral Tablet

(loperamide) (Skidmore-Roth, 2015, p. 721).

2 MG 2 Tablet PO PRN Every 6 Hours

Direct action on intestinal

muscles to decrease GI peristalsis; reduces volume, increases bulk; electrolytes not lost

Antidiarrheal

Diarrhea

Meclizine HCL Oral Tablet

(Antivert/Bonine)

(Skidmore-Roth, 2015, p. 746).

25 MG 1 Tablet PO PRN Every 6 Hours

Acts centrally by blocking chemoreceptor trigger zone, which in turn acts on vomiting center

Antiemetic, antihistamine, anticholinergic

Motion Sickness, Vertigo

Milk of Magnesia Oral Suspension

(Skidmore-Roth, 2015, p. 738).

1200 MG/15ML 30 Milliliter PO PRN 1X Daily

Increases osmotic pressure and pulls fluid into colon, successfully neutralizing HCl

Antacid, electrolyte; saline laxative, anticonvulsant

Constipation

Ondansetron HCL Oral Tablet

(Zofran)

(Skidmore-Roth, 2015, p. 886).

4 MG 1 Tablet PO PRN Every 6 Hours

Prevents nausea, vomiting by blocking serotonin peripherally, centrally, and in the small intestine

Antiemetic

Prevention of nausea, vomiting

Other Diagnostic Tests:

Test

Results

Significance

04/04/16

CT Head/Brain w/o Contrast

Atrophy and ischemic microangiopathic changes are present with no acute intracranial hemorrhage Mass nor mass effect is seen.

Consistent with patient's diagnosis of syncope.

04/04/16 CTA Chest w/wo Contrast

There is no evidence of pulmonary embolus. The thoracic aorta is normal in caliber with no aneurysm or dissection demonstrated.

Stable atelectasis at the right lung base.

Cholelithiasis is present.

Right thyroid nodule is present.

Consistent with patient's diagnosis of syncope and AF.

04/05/16 CT Head/Brian w/o Contrast

No new acute intracranial abnormality including no acute hemorrhage or identifiable recent territorial infarct seen

Follow-up recent syncope and fall.

04/09/16 MRA Head w/o Contrast

No perfusion or diffusion weighted abnormality is seen. There is a tiny probable punctate old microhemorrhage in the posterior left centrum semiovale. There is cerebral atrophy and periventricular white matter small vessel ischemic changes. There is no evidence for acute territorial infarction or intra-cranial hemorrhage. No mass or midline shift is seen.

Left-sided weakness and suspected stroke.

04/09/16 MRI Brain w/wo Contrast

Atrophy and small vessel ischemic changes. No definite acute intracranial abnormality.

Normal MR angiography of the circle of Willis.

Left-sided weakness and suspected stroke.

04/09/16 U.S./VAS Duplex Carotid Arteries Bilateral

Calcified plaque without hemodynamically significant stenosis of the right internal carotid artery.

Calcified plaque without hemodynamically significant stenosis of the left internal carotid artery.

Patient is undergoing stroke evaluation.

Flow Chart: don't have to do the chart, please describe (not define) these terms, include references (not older than 5 years):

Cardiovascular Syncope

A very common occurrence among Americans, affecting over 3 million people a year, a cardiovascular syncope refers to when a person suddenly collapses or faints due to a malady of heart rhythm where there is an absent or slow pule leafing to fainting (syncope) without or with convulsions. Essentially, there is disruption in the normal heartbeat passing from the upper to the lower chambers of the heart; a sort of 'heart block'. Heart blocks results in considerably slow heart rates causing insufficient blood flow to a person's brain, resulting in syncope.

Hypertension

Hypertension is another name for high blood pressure. While people can have high blood pressure for several years without showing any symptoms, eventually hypertension can lead to heart disease. This is because of the long-term force of blood against artery walls being high enough to cause health problems. Damaged blood vessels can lead to stroke and heart attack.

Hyperlipidemia

Affecting more than 3 million people annually, it is a condition where an individual experiences high levels of lipids or fat particles in the blood. Lipids are triglycerides and cholesterol and often deposit in an individual's blood vessel walls, restricting blood flow (Carpenito, 2013, p. 640). Without any symptoms, it can be diagnosed via the use of routine blood tests ever five years for adults and can be treated through exercise, a healthy diet, and medication.

Coronary Atherosclerosis

Leading to a slow narrowing and hardening of the arteries in the heart, coronary artery disease is often regarded as the #1 killer of Americans, because it leads to a sudden blood clot in the heart's arteries that circulates and becomes stuck leading to a heart attack or stroke.

Atrial Fibrillation

A rapid and irregular heart rate typically causing poor flow is a key sign of atrial fibrillation and shows no symptoms. When symptoms do appear, they include fatigue, shortness of breath, and palpitations. This disorder occurs when a person's heart's atria beat out of sync with the ventricles. Treatments include cardioversion, drugs, as well as minimally invasive surgery or ablation "AF is associated with atrial fibrosis and loss of muscle mass" (Ignatavicius & Workman, 2013, p. 761).

Congestive Heart Failure

Affecting more than 200,000 American annually, heart failure happens when a heart fails to pump or fill sufficiently. Symptoms include swollen legs, shortness of breath, and rapid heartbeat. Life style changes like a less salt diet and limitation of fluid intake can help treat the condition along with implantation of a pacemaker or defibrillator in some cases. A common sign of heart failure is difficulty breathing, bilateral edema, and rapid weight gain (Ignatavicius & Workman, 2013, p. 1429).

Physical Diagnoses

1. Impaired physical mobility r/t decreased muscle strength, pain on his legs, activity intolerance and deconditioning AEB slowed movement, postural instability -- standing and walking, inability to move or transfer (Doenges et al., 2013, p. 611-612).

2. Self-care deficit: bathing, dressing, feeding, toileting r/t muscle weakness on lower extremities, pain on his legs, impaired mobility AEB inability to perform ADLs -- inability to get to the bathroom independently (Doenges et al., 2013, p. 787-788).

Psychosocial Diagnoses

1. Impaired comfort r/t stabbing pain on patient's legs that he gets every evening AEB self-reported of being uncomfortable, lack of ease in situation and disturbed sleep pattern (Doenges et al., 2013, p. 210-211).

2. Hopelessness r/t prolonged activity resection, deteriorating physiological condition, loss of self-independence AEB patient belief things will not get better for him and patient stated "I will never get out of here" (Doenges et al., 2013, p. 485-486).

Plan:

Diagnosis: Impaired physical mobility r/t decreased muscle strength, pain on his legs, activity intolerance and deconditioning AEB slowed movement, postural instability -- standing and walking, inability to move or transfer (Doenges et al., 2013, p. 611-612).

Expected Outcome

Nursing Intervention

Evaluation/Change in Plan

Short-Term Goals:

1. Towards the completion of the shift, the patient will participate in passive ROM of both legs 3X daily.

2. Towards the completion of the shift, expectations are patient will be able to securely alter position as well as execute transfers every two hours with help from assistive devices and medical personnel.

3. Towards the completion of the shift, patient will be able to exhibit the utilization of scanning methods to increase visual field to encompass left side every two hours throughout the assisted transfers and repositioning.

Long-Term Goal:

4. The patient will achieve increased mobility, remain free of any complications such as swelling, deep vein thrombosis, and may be able to achieve self-care such as bathing through improved stability.

Collaboration with physical therapist or occupational therapist to provide passive ROM, as well as isotonic muscle contractions, activities, and assistive devices.

Rationale: To advance mobility program in conjunction with individualized exercise, to recognize suitable mobility devices, and to minimize or limit effects and complications of immobility (Doenges, Moorhouse, & Murr, 2014 p. 610). Evidence shows the application of passive ROM can increase range of function, motion, including activities of daily living.

(Chang et al., 2014). Rational: To circumvent stress and injury.

Support the client to shift on a consistent schedule (Doenges et al., p. 614).

Rational: To increase compliance and awareness

Instruct patient on common complications of CVA together with mobility neglect and why it is imperative to remain active while recovering. Rational: To increase mindfulness and acquiescence with treatment.

Instruct patient on methods to scan manual rotation of the head/neck full ROM and offer support when necessary.

Rational: Promote movement of legs by offering positive reinforcement and increasing desire for participation.

By using gel pads, orthopedic shoes, and body pillows, these will offer support to affected body parts.

Rational: Improves self-concept as well as sense of independence. (Doenges, Moorhouse, & Murr, 2014, p. 614).

Offer safety measures including fall prevention and environmental management.

Rational: Prevent injury

Placement of call bell near patient with instruction provided on its use and verification that patient can use call bell correctly.

1. Goal partially met: With support from nurse, patient partook in passive ROM of the both legs two to three times daily. The patient was unwilling and declined to join due to his muscle weakness one time.

Change in plan: Need second consultation with OT and PT. The patient is more eager to achieve passive ROM when encouraged and supported. Offer increased support and motivational speaking to enhance participation.

2. Goal met: The patient's mobility increased and he was able to alter position every two hours with suppoer and assistive devices like a Hoyer lift.

3. Goal is met: Thanks to encouragement from nurse and additional assistance, patient was able to increase mobility after utilization of appropriate scanning techniques.

4. Goal partially met: Patient has no indication deep vein thrombosis or pressure ulcer. However, he did feel tired and lethargic at times.

Change in plan: Consultation with physician is necessary along with a development of a routine schedule to alter patient's exercise to increase strength and movement.

Diagnosis: Impaired comfort r/t stabbing pain on patient's legs that he gets every evening AEB self-reported of being uncomfortable, lack of ease in situation and disturbed sleep pattern (Doenges et al., 2013, p. 210-211).

Expected Outcome

Nursing Intervention

Evaluation/Change in Plan

Short-Term Goals:

1. Assess for any presence of pain

2. Assist in identifying and quantifying pain, including type of pain, location, plus intensity on an established pain-rating scale (Doenges, Moorhouse, & Murr, 2014, p. 256).

3. Help patient with identifying any underlying precipitating factors

Long-Term Goal:

4. Offer comfort measures, such as massage, position changes, ROM exercises, including use of cold or warm packs, as indicated.

Rational: Improves pain management Administration of medications, as indicated like effective muscle relaxants baclofen (Lioresal), dantrolene (Dantrium), and analgesiscs. Anti-anxiety agents like diazepam (Valium) and alprazolam (Xanax) can also prove useful (Doenges, Moorhouse, & Murr, 2014, p. 256).

Rational: Improves self-concept and well-being. Diversional and relaxation activities will help client refocus attention as well as promote sense of control, possibly improving coping abilities.

Rational: Improve anxiety

Expression of feelings as well as pain will assist client in coping effectively with pain by letting someone know what bothers him and how he feels about it. Self-awareness of problems can lead to relief of symptoms (Doenges, Moorhouse, & Murr, 2014, p. 312).

Rational: Improve restlessness and irritability

Assess client for nonverbal cues that are indicative of discomfort and pain. External temperature extremes or sitting for longer periods of time can exacerbate pain in the legs (Doenges, Moorhouse, & Murr, 2014, p. 257).

1. Goal is not met: Client learned to express emotions effectively and freely, letting staff know of any pain and discomfort.

Change in plan (if goal is partially met or not met): However, there is still pain leading to sleep disturbances. Changes in pain medication and physician consultation may prove helpful.

2. Goal partially met: Client is feeling less anxious and is able to get at least 5 hours of sleep.

3. Goal is met: Client is able to provide accurate information on pain by expressing pain rating on pain rating scale.

4. Goal partially met: Massage and physical therapy has alleviated pain in other areas, leading to enhanced mobility and reduction in stabbing pain.